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The American Academy of Orthopaedic Surgeons (AAOS) recently released updated guidelines for the management of hip osteoarthritis (OA). The full report has been published on the organization’s official website.1
The updated guidelines are a revision of the 2017 edition, introducing modifications to 14 of the 23 evidence-based recommendations for the nonoperative treatment of hip OA in adults. These revisions yielded 3 strong recommendations, 5 moderate recommendations, and the remaining were of limited nature. 2 The guidelines covered various recommendations supported by substantial evidence and options for treatment supported by lower quality evidence.
Recommendations for the Management of Hip OA
Tranexamic Acid (TXA) in Individuals Undergoing Total Hip Arthroplasty (THA):
- For the pharmacological management of individuals with symptomatic hip OA who are undergoing THA, the use of both intravenous and topical TXA is strongly recommended.
- TXA is effective for reducing the chances of blood loss and the necessity for blood transfusions in these patients, while potentially improving outcomes and maintaining a low risk for adverse events.
Intra-Articular Hyaluronic Acid:
- For the pharmacological management of individuals with hip OA, the use of intra-articular hyaluronic acid is strongly not recommended.
- The use of intra-articular hyaluronic acid does not demonstrate superior efficacy for improving function or alleviating pain when compared with a placebo.
Nonsteroidal Anti-Inflammatory Drug (NSAID) Use for Pharmacological Pain Management:
- For the pharmacological management of individuals with hip OA, the use of oral NSAIDs is strongly recommended for the treatment of pain and enhancing functionality, provided there are no contraindications.
- The use of oral NSAIDs for nonoperative treatment in symptomatic hip OA can be easily incorporated into treatment regimens, emphasizing the pivotal role of nonopioid medications in reducing reliance on opioids.
Postoperative Physical Therapy:
- For the postoperative management of individuals with hip OA following THA, the use of both formal physical therapy or unsupervised home exercise is moderately recommended.
- Regular exercise is crucial for a successful postoperative recovery; however, suggesting home exercise without proper guidance may impede outcomes for individuals who require structured rehabilitation.
- Currently, there is a lack of identification of appropriate candidates for home exercise vs supervised therapy, potentially resulting in delayed recognition of negative outcomes.
- The strength of this recommendation was lowered to moderate due to difficulty comparing studies with variations in physical therapy interventions — including duration and frequency — and a lack of studies directly comparing progressive outpatient physical therapy with an active placebo group during the critical 3-month postsurgery period.
Physical Therapy as Conservative Treatment:
- For the treatment of mild to moderate symptomatic hip OA, physical therapy is moderately recommended.
- Individuals who qualify for conservative treatment may find advantages in pursuing physical therapy to optimize range of motion, alleviate pain, and enhance overall functionality.
- The strength of this recommendation was lowered to moderate due to variations in modalities, interventions, and significant heterogeneity in the frequency, duration, and intensity within intervention groups.
Intra-Articular Corticosteroids:
- For the pharmacological management of individuals with hip OA, the use of intra-articular corticosteroids is moderately recommended.
- The use of intra-articular corticosteroids may enhance short-term function and alleviate pain for patients experiencing symptomatic OA of the hip.
- The strength of this recommendation was lowered to moderate due to differences in study design, corticosteroid dosage, and inadequate reporting of adverse events.
Cemented Femoral Fixation:
- For the management of older individuals with symptomatic hip OA who are undergoing THA, the potential use of cemented femoral stems is moderately recommended and its use should be implemented with an individualized approach.
- The use of cemented femoral stems in older individuals may be associated with a decreased risk for subsequent periprosthetic fracture; however, there is a possibility for bone cement implantation syndrome among certain decompensated patient populations.
- The strength of this recommendation has been elevated to moderate, emphasizing the importance of addressing the risk for periprosthetic fractures in THA. This is in response to the widespread adoption of cementless femoral stems, driven by factors such as the effectiveness of biologic ingrowth fixation, shorter operation times, reduced risk for embolic debris, and a lack of training in the cement technique.
Individualized Exposure Approach:
- § For the management of individuals with symptomatic hip OA undergoing THA, an individualized surgical approach is moderately recommended. Considering there are specific risks and benefits for each, no preferred surgical approach can be identified based on the current evidence.
- The strength of this recommendation has been decreased to moderate due to data heterogeneity, the indirectness of comparative studies, and the potential for future research to impact the recommendation.
Options for the Management of Hip OA
Impact of Body Mass Index (BMI) on Adverse Events:
- For the management of individuals with symptomatic hip OA who are undergoing THA, limited evidence suggests that an increased BMI may heighten the risk for adverse events.
- Assuming elevated BMI is a modifiable risk factor, it is valuable to explore any link between BMI and adverse events post-THA.
Impact of BMI on Clinical Outcomes:
- For the management of individuals with symptomatic hip OA who have received THA, limited evidence indicates that individuals with increased BMI may achieve lower absolute patient-reported outcome scores. However, these individuals still experience a comparable level of improvement in patient satisfaction, pain, function, and quality of life.
Impact of Diabetes on Adverse Events:
- For the management of individuals with symptomatic hip OA who have received THA, there islimited evidence indicating that individuals with uncontrolled diabetes may be at a higher risk for adverse events.
- There is currently no consensus regarding a safe HbA1c level for surgery, and uncontrolled diabetes amplifies the risks associated with THA.
- The decision to proceed with surgical treatment should be collaborative, weighing individual risks and benefits, as infection and renal injury pose significant morbidity and potential mortality.
Impact of Social Determinants of Health on Outcomes:
- For the management of individuals with symptomatic hip OA undergoing THA, there is limited evidence indicating that factors such as education, income level, and insurance type impact the length of stay, total cost of care, and mortality among these patients.
- Low-quality studies suggest that social determinants of health influence THA outcomes, underscoring the significant importance of addressing equity in the context of prevalent negative social determinants.
Impact of Neuraxial Anesthesia on Adverse Events:
- For the management of individuals with symptomatic hip OA undergoing THA, limited evidence indicates that neuraxial anesthesia may be employed to decrease adverse events in these patients.
- While neuraxial anesthesia has been associated with a reduction in adverse events, the choice of anesthesia should be tailored to each patient, taking into account their medical conditions and weighing the potential risks vs benefits.
Impact of Tobacco on Adverse Events:
- For the management of individuals with symptomatic hip OA who have received THA, limited evidence suggests an elevated risk for adverse events in patients who use tobacco products.
Prescription Opioids as Conservative Treatment:
- For the management of individuals with symptomatic hip OA, there is insufficient evidence on the use of prescription opioids as nonoperative treatment.
- The guideline authors do not advise the use of oral opioids for nonoperative management.
- Opioids provide minimal clinical benefit and carry significant adverse effects, while also increasing complications post-THA.
Pharmacological Management With Acetaminophen:
- For the management of individuals with symptomatic hip OA, due to insufficient evidence, the guideline authorssuggest considering oral acetaminophen when not contraindicated for pain management.
- The use of acetaminophen for nonoperative treatment may alleviate pain and enhance functionality in eligible individuals.
- Nonopioid medications like acetaminophen are key for the nonoperative treatment of symptomatic hip OA and for reducing opioid usage. However, caution should be exercised due to contraindications when using oral acetaminophen, including pre-existing liver disease.
Impact of the Hip-Spine Relationship on Outcomes:
- For the management of individuals with symptomatic hip OA, there is insufficient evidence on the relationship between hip OA and stiff spine syndrome.
- The guideline authors believe individuals with hip OA and stiff spine syndrome may face an increased risk for dislocation following THA, compared against patients without this syndrome.
- Dislocation, a significant complication in THA, may be influenced by the hip-spine relationship, but substantial data is lacking.
- Despite potential complications, patients with stiff spines should not be precluded from surgery, emphasizing the need for individualized approaches and open discussion between surgeons and patients.
- The strength of this recommendation has been decreased due to the heterogeneity of data and reported timepoints, with future research expected to significantly impact this recommendation.
This comprehensive guideline update offers evidence-based recommendations for managing symptomatic hip OA. Individualized approaches are emphasized, considering factors such as pharmacological interventions, physical therapy, surgical choices, and patient-specific conditions. This update aims to enhance patient outcomes, minimize complications, and guide healthcare professionals in delivering optimal care for patients with symptomatic hip osteoarthritis.
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Research findings have consistently highlighted numerous factors that negatively affect the accessibility and quality of health care for transgender and gender-diverse (TGD) individuals. In addition to substantial socioeconomic barriers, studies have shown that TGD patients often experience stigma, discrimination, denial of services, and a lack of competent care in health care settings.1-3 In light of these ongoing disparities, there have been increasing calls for culturally competent, gender-affirming care for patients of all gender identities.4,5
According to guidelines published in February 2024 in Fertility and Sterility, the Practice Committee of the American Society for Reproductive Medicine (ASRM) opines the use of inclusive language as a key factor in creating a welcoming environment for lesbian, gay, bisexual, transgender, queer, questioning, intersex, and asexual+ (LGBTQIA+) individuals.
For example, the Committee recommends that providers and staff: (1) ask patients which pronouns and names they use (rather than asking which ones they prefer); (2) avoid using heteronormative and cis-normative language such as “husband” or “mom” in favor of more neutral terms such as “partner” and “parent”; (3) and, use clinical forms that contain language representative of all sexual orientations and gender identities.4
This increasing emphasis on using gender-inclusive language has illuminated the limitations of the term “women’s health” to describe the needs and services of all individuals who need such care.6,7
To glean expert insights on reconceptualizing this concept to be more inclusive of TGD individuals, we interviewed ASRM president Paula Amato, MD, MCR, professor in the department of obstetrics and gynecology and director of the division of reproductive endocrinology and infertility at Oregon Health and Science University School of Medicine in Portland, and Beth Cronin, MD, clinical associate professor of obstetrics and gynecology at the Warren Alpert Medical School of Brown University in Providence, Rhode Island.
What does the concept of “women's health” mean in general?
Dr Amato: Women's health care traditionally includes sexual, reproductive, gynecologic, and obstetric care. Exclusionary policies and behaviors in health care often marginalize gender-non-conforming patients and contribute to health disparities. Furthermore, social determinants of health have the potential to act as drivers of health disparities and create barriers to high-quality health care.
Women's health also includes conditions that affect women differently, disproportionately, or have historically had a bias in delivery of care to women.
Gender-inclusive care means to offer health care in which each patient's self-defined gender identity — which may differ from the sex assigned at birth — is understood, supported, and affirmed.
Dr Cronin: Traditionally, the term “women’s health” encompassed the care of cisgender women throughout their lifespan, including management of gynecologic issues such as abnormal pap smears, sexually transmitted infections (STIs), pelvic pain, abnormal bleeding, contraception, and menopause, as well as pregnancy-related care, including miscarriage, abortion, and prenatal and postpartum care.
This [term] has also encompassed a focus on the difference between males and females in cardiac disease and management of the aging process. If you ask different folks working in different spheres of the health care spectrum, you will likely get varied answers regarding the meaning of women’s health.
Should the concept of women’s health care expand to include transgender women? How about transgender men?
Dr Amato: Transgender women are women and should be included and affirmed in women's health care spaces. Non-binary and transmasculine people with female anatomy should also be able to access expert care without fear of discrimination or harm.
Dr Cronin: “Women’s health” is a problematic term in many spaces for exactly this reason — as it can be a term that excludes others who need the care of the health care team which is traditionally provided in the women’s health space. We should be working to be as inclusive as possible with our language.
Transgender women will often seek and need care in OBGYN offices, family practice offices, and other spaces providing this care, and they should and need to be welcomed. Transgender men and nonbinary individuals with a uterus need to access care traditionally thought of as “women’s health” for a variety of reasons — including STI testing, cervical cancer screening, menstrual suppression, contraception, and pregnancy-related care.
Walking into a women’s health clinic can be extremely challenging and can cause dysphoria if one doesn’t identify as a woman. OBGYNs treat people of all gender identities, including people who are cisgender, transgender, gender non-binary, or otherwise gender expansive.
What are other potential negative consequences of using terms like “women’s health,” and what language should providers consider using instead?
Dr Amato: Health care providers may inadvertently alienate and exclude transgender men, transmasculine people, and non-binary and gender-non-confirming people assigned female at birth. These are people who may require women's health care but do not identify as women.
Clinical recommendations include: (1) set a welcoming tone; (2) use gender-inclusive language; (3) focus on anatomy, conditions, and symptoms rather than gender; and, (4) practice person-centered care.
Dr Cronin: Patients may not seek care due to issues such as discomfort and feeling like they won’t be welcomed. Language should be centered around the care that is provided — for example, changing the name from “Women’s Health Clinic” to “Obstetrics and Gynecologic Clinic.” Clinicians should try to eliminate gender-specific language and use inclusive terms whenever possible, such as “pregnant person” or “birthing people” instead of “pregnant women.”
How can health care providers make space for TGD patients within the realm of what has traditionally been referred to as “women's health,” and what are some ways for providers to further build competence in providing optimal care to these individuals?
Dr Amato: I recommend the following measures for providers and practices:
- Develop a diverse training and education pipeline.
- Use intentional and strategic efforts to diversify the workforce.
- Utilize policies, forms, and hiring practices that are inclusive of all identities.
- Avoid assumptions about gender identity and anatomy.
- Collect information on gender identity and sexual orientation.
- Use inclusive language on intake forms and when communicating with patients, and be willing to ask patients what language they prefer.
- Display brochures and educational materials about LGBTQ health concerns.
- Visibly post a non-discrimination statement.
- Display posters from non-profit LGBTQ organizations.
- Have at least 1 gender-neutral restroom available.
- Support policy and legislation that advances equity and centers reproductive justice.
Dr Cronin: Health care providers need to educate themselves by taking advantage of seminars, webinars, and other online resources to understand the importance of making their practice inclusive, welcoming, and affirming for all patients.5,8,9 It is critical at this time that clinicians provide a safe space for patients to access care.
Broadly, what are some of the key ongoing issues and needs regarding the provision of culturally competent care for TGD populations?
Dr Cronin: One of the most pressing issues currently is the outright attacks on transgender individuals across our country. Legislation has been introduced in almost every state to challenge access to necessary health care for transgender individuals. We need to stand behind thoughtful, evidence-based medicine and use our voices as experts, as health care providers, to center the patient in the fight to maintain access to care.
Ongoing research is needed to further best practices, examine advances in the field, advance surgical techniques, and ultimately provide the best possible care for patients.10
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The American College of Physicians (ACP) has published an update to the 2017 version of its recommendations regarding newer pharmacologic treatments for type 2 diabetes, including glucagon-like peptide-1 (GLP-1) agonists, sodium-glucose cotransporter-2 (SGLT-2) inhibitors, dipeptidyl peptidase-4 (DPP-4) inhibitors, and long-acting insulins. The full update was published in Annals of Internal Medicine.
In 2017, the ACP recommended metformin as an adjunct to lifestyle modifications to improve glycemic control among adults with type 2 diabetes. However, 16% of adults with type 2 diabetes have inadequate glycemic control, which is most prevalent among Black and Hispanic adults compared with White adults.
To assess the effectiveness of type 2 diabetes treatments in reducing all-cause mortality, cardiovascular morbidity, and chronic kidney disease (CKD) progression, the Clinical Guidelines Committee of the ACP conducted a systematic review and network meta-analysis of randomized controlled trials with a duration of at least 12 months.
Critical outcomes included all-cause mortality, congestive heart failure (CHF), major adverse cardiovascular events (MACE), myocardial infarction alone, progression of CKD, serious adverse events, and severe hypoglycemia. The ACP also assessed patient values and preferences for new treatments, as well as the costs and economic burden of care.
Clinical Considerations
The ACP recommendations apply to nonpregnant adults with long-standing type 2 diabetes and a mean hemoglobin A1c (HbA1c) of approximately 8%. Because evidence was insufficient to differentiate between patients with and without cardiovascular disease or CKD, these recommendations apply to patients regardless of cardiovascular disease or CKD status.
Metformin and lifestyle modifications should remain the first line of treatment for managing type 2 diabetes. When considering additional therapy, clinicians should weigh benefits vs harms, cost of medications, and individual patient factors such as comorbid conditions and glycemic control targets.
"
Benefits and harms of additional pharmacologic treatment beyond the initial add-on treatment are unknown (for example, a patient who receives metformin plus an SGLT-2 inhibitor but in the future receives an additional GLP-1 agonist).
Glycemic control targets should include considerations for hypoglycemia risks, life expectancy, diabetes duration, comorbidities, capacity for self-monitoring, and access to resources. The ACP recommends glycemic control target values between 7% and 8% for most adults with type 2 diabetes. For adults with HbA1c levels below 6.5%, clinicians should attenuate pharmacologic treatments.
SGLT-2 Inhibitors and GLP-1 Agonists
The ACP recommends prescribing an SGLT-2 inhibitor or GLP-1 agonist as an adjunct to metformin and lifestyle modifications to improve glycemic control among adults with type 2 diabetes. Among patients receiving metformin and SGLT-2 inhibitor or GLP-1 agonist combination therapy, blood glucose self-monitoring may be unnecessary.
Specifically, the ACP recommends SGLT-2 inhibitors to reduce the risks for all-cause mortality, MACE, progression of CKD, and hospitalization due to CHF. To reduce the risk for all-cause mortality, MACE, and stroke, GLP-1 agonists are recommended.
In the cost-effectiveness analysis, the ACP identified no significant differences between SGLT-2 inhibitors and GLP-1 agonists.
According to the ACP, SGLT-2 inhibitors should be prioritized for patients with type 2 diabetes and CHF or CKD, whereas GLP-1 agonists should be prioritized for patients with type 2 diabetes and an increased risk for stroke or total body weight loss goals.
The ACP also recommends the reduction or discontinuation of sulfonylureas or long-acting insulin treatments when adding an SGLT-2 inhibitor or GLP-1 agonist to a patient’s treatment regimen. Compared with SGLT-2 inhibitors and GLP-1 agonists, sulfonylureas and long-acting insulins were less effective for reducing all-cause mortality and morbidity.
DPP-4 Inhibitors
The ACP recommends against prescribing a DPP-4 inhibitor as an adjunct to metformin and lifestyle modifications to improve glycemic control among adults with type 2 diabetes.
In their analysis, the ACP identified no differences in the critical outcomes between patients prescribed adjunctive DPP-4 inhibitors and those who received usual care. Compared with GLP-1 agonists, DPP-4 inhibitors likely increase the risks for all-cause mortality, hospitalization due to CHF, and MACE.
“Benefits and harms of additional pharmacologic treatment beyond the initial add-on treatment are unknown (for example, a patient who receives metformin plus an SGLT-2 inhibitor but in the future receives an additional GLP-1 agonist),” the ACP concluded. “Further, clinical evidence on patient mortality, morbidity, and hospitalizations and economic evidence are lacking for use of SGLT-2 inhibitors and GLP-1 agonists as initial treatment for patients with type 2 diabetes.”
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This month, we look at a reproductive endocrinology case that discussed wrongful birth vs wrongful life lawsuits. In it, a New York court had to decide whether the statute of limitations runs from the act of negligence or the birth of the child.
Facts of the Case
Mr and Mrs. F were desperate to have a baby. The couple had been trying to conceive naturally and finally decided to seek medical help. They made an appointment with Dr C, the head physician at a large reproductive endocrinology practice, to discuss in vitro fertilization (IVF). Dr C explained the IVF process, telling the couple that the practice screened egg donor candidates for genetic diseases and other conditions. However, he did not disclose which specific conditions he screened for or the reasoning behind the screening process.
The couple were put on the waiting list for an egg donor. Months later, they were matched with a donor, whom they accepted. Mr and Mrs. F signed a consent form agreeing to go ahead with the IVF procedure. The consent form contained language stating that the prospective parents “understand that the risk of major birth defects following the use of donor eggs appears to be the same as in the general population.”
In January, 2 embryos were implanted into Mrs. F. The embryos were produced by fertilizing donated ovum with Mr F’s sperm. Much to the couple’s delight, they were pregnant soon after. Mrs. F’s final appointment with Dr C was in March. In September, Mrs. F gave birth to twin boys.
The following February, Dr C received information that Mr and Mrs. F’s egg donor might have a genetic mutation. He had the donor come in to be tested for a chromosomal abnormality known as Fragile X, which can produce intellectual impairment and other disabilities, particularly in boys.
The donor turned out to be a carrier for the condition. She had not been tested for it prior to donating eggs to Mr and Mrs. F. That May, Dr C called Mrs. F and notified her that the egg donor was a Fragile X carrier. Mr and Mrs. F had their sons tested for the condition and learned that one of them had the full mutation.
A year and a half later, Mr and Mrs. F sued Dr C and his practice for a dozen causes of action, including medical negligence, breach of contract, and negligent misrepresentation.
The physician retained an attorney who moved to dismiss half of the claims. Specifically, the attorney asked to dismiss any claims made on behalf of the impaired child. The court granted the defendant’s request, holding that such claims would amount to a “wrongful life” claim that is not recognized in New York. Parents cannot bring a claim on behalf of the child arguing that the child would have been better off not being born. Parents can, however, bring a claim for wrongful birth, if they can establish that the child would not have been conceived but for the defendant’s malpractice or that the malpractice deprived them of the opportunity to terminate the pregnancy.
The court dismissed the wrongful life claims but allowed the wrongful birth claims to proceed. At this point, the physician moved to have the remining claims dismissed. The physician argued that the statute of limitations for a medical malpractice case is 2½ years, and that the last time he had treated the patient was over 2½ years earlier. Thus, the physician claimed, the lawsuit was barred by the statute of limitations. The parents argued that the statute of limitations should run from the birth of the child — not the last time the mother was treated by Dr C. The case went to the state’s highest court for a decision on this issue.
Legal Background
The court noted that in 1978 it recognized a new cause of action allowing parents to recover for the extraordinary care and treatment expenses resulting from the birth of a child with a disability (ie, wrongful birth). However, the claim is restricted to the following instance: The plaintiffs have to show that, if it weren’t for the defendant’s breach of duty to advise the plaintiffs, they would not have been required to assume the extraordinary financial expenses. Parents bringing this kind of action can only recover for the increased financial obligation that they incurred by having a child with a disability. Parents cannot seek compensation for emotional damage or the ordinary costs of raising a healthy child.
"
Wrongful birth claims, however, are designed to provide parents with financial compensation to offset the costs involved with raising a child with birth defects. In such cases, the statute of limitations does not begin to run until the birth of the child.
“The question now before this Court is when this ‘extraordinary expenses’ cause of action accrues — and consequently when the statute of limitations begins to run,” the court noted in its decision. Dr C argued that it was the date of the malpractice, whereas Mr and Mrs. F argued that it was at the date of the child’s birth.
“Plaintiffs allege that, by failing to take steps to detect that the egg donor was a carrier for Fragile X and therefore that the embryo may have had the Fragile X trait, defendants left the parents in an uninformed state as to whether to avert pregnancy or birth — and the associated costs resulting from birth. Given the nature of these allegations, it follows that until the alleged misconduct results in the birth of a child, there can be no extraordinary expenses claim,” the court held in its decision.
“Prior to a live birth, it is impossible to ascertain whether parents will bear any extraordinary expenses. Due to these unique circumstances, the cause of action accrues upon the birth of an infant with a disability,” the court declared. The court allowed the case to stand against the physician.
Protecting Yourself
It’s important to know the difference between a wrongful birth claim and a wrongful life claim. Less than a handful of states allow wrongful life claims. A wrongful life case would be filed on behalf of the child with a disability, with the argument: Were it not for the negligence of the defendant, the plaintiff would not have been born. Courts have traditionally been very reluctant to award damages in these types of cases, and the vast majority of jurisdictions do not allow such claims.
Wrongful birth claims, however, are designed to provide parents with financial compensation to offset the costs involved with raising a child with birth defects. In such cases, the statute of limitations does not begin to run until the birth of the child.
Dr C’s failure to screen for Fragile X affected more than just Mr and Mrs. F. A second couple with a very similar case consolidated their legal matter with this case for that reason. The second couple used the same doctor and egg donor and subsequently gave birth to a son, who had the Fragile X abnormality. Dr C should have (1) told his patients exactly which conditions he was screening the donors for, and (2) used a more comprehensive screening panel.
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